Leading Better Value Care
Local vignette – Illawarra Shoalhaven LHD

Chronic obstructive pulmonary disease

Respiratory coordinated care program – a clinician's perspective

By Nick Spiliopoulos

28 Apr 2021 Reading time approximately

What is important to know about your service?

The population of Shoalhaven is around 105,000 people. The geographical area covers 4,660 square kilometres. Twenty-seven percent of the population are older than 65 years. The Respiratory Coordinated Care Program (RCCP) is based at Shoalhaven District Memorial Hospital. This is a rural hospital with about 160 beds. There is one other private hospital in the area and 20 aged care facilities. Chronic obstructive pulmonary disease (COPD) is one of the top 10 diagnosis-related groups (DRG) for the hospital.

What organisational model do you use?

Multidisciplinary team approach.

Diagnostic testing
leads to
Exacerbation management
leads to
Ongoing care
leads to
Last year of life

What is special about the way care is delivered that is valuable for others to know?

The RCPP is a hospital-based program with home visits designed to assist people with chronic lung disease, in particularly, advanced COPD (DRG groupings E65A/E65B).

The multidisciplinary team includes: a respiratory clinical nurse consultant (1 full-time equivalent (FTE)), two physiotherapists (0.71 FTE), an occupational therapist (0.21 FTE) and a pharmacist (0.03 FTE). The program is supported by respiratory specialists.

Eligibility criteria includes: 60 years of age (or under 45 years for Aboriginal people); severe COPD (FEV1 <50% predicted) or advanced lung disease; at least two respiratory admissions in the previous 12 months; cognitively intact and psychosocially well; care optimised by a respiratory physician; and approval from the patient’s general practitioner.

The following interventions are available through the program: outpatient pulmonary rehabilitation plus maintenance; pre and post spirometry assessments; respiratory assessment and monitoring; medication and delivery device review; physiotherapy, occupational therapy assessment and intervention, non-invasive ventilation review and education; oxygen review and education; smoking cessation support and COPD action plans.

Home visits occur on a regular basis to patients recruited to the program, in addition to home visits post-hospital discharge if there is a high-risk of readmission to hospital. By seeing enrolled patients regularly means the RCCP staff can respond to patients as the “first point of contact” to avoid unplanned admissions (between 8:00am-4:30pm) and also refer patients to the respiratory clinic when unwell instead of the emergency department. The RCCP will also refer to other disciplines when necessary.

A companion document describes options for organisational models in COPD. One option is a Respiratory Coordinated Care Program – this vignette describes the model from a local perspective.

How does it make a difference?

Patients are confident contacting program staff as the first point of contact, thereby circumventing calls to ambulance services. COPD episodes have reduced by 44%, readmissions by 77%, and hospital length of stay by 21% from 2015-2018.

What tips do you have for others?

  • Pilot the RCCP to demonstrate savings via activity based funding.
  • Quantify savings to the facility and organisation in dollar terms (real and potential) to build your care for investment in the RCCP.

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